When news first broke in mid-December 2020 that the FDA had issued an emergency use authorization for a Covid-19 vaccine that was astonishingly effective, providers and staff at my clinic asked me in eager anticipation, “Will we be vaccinating seniors in our practice?”
My answer, as the administrator of the practice, was simple and unequivocal, “Absolutely.”
We had just witnessed the fastest vaccine development process in history, thanks to the ingenuity and perseverance of countless scientists, technologists, and entrepreneurs worldwide. Making the fruits of their labor available to the patients of our practice, TotalCare Walk-In Clinic in Chino, Calif., was the least we could do. Opportunity knocked on Dec. 28, 2020, in an email from the San Bernardino County Medical Society on behalf of the county public health department, asking to sign up our practice as an independent vaccine administration site. I replied within minutes, excited to play an active role in helping end the worst pandemic in modern history.
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Two months later, after we’ve administered Covid-19 vaccines to more than 400 seniors in our two clinics, I’ve begun to question my decision. The challenge isn’t the vaccination process itself — we smoothly administer 1,500 flu shots every winter — but in responsibly handling the pre- and post-vaccination processes. For every minute we spend preparing and injecting the vaccine, we spend another 30 minutes coordinating the logistics of the appointment and answering the patient’s questions.
Meeting the minimum order thresholds and following the impossibly strict timelines set by the California Department of Public Health, all while treating each senior not just as a target for a shot but as a human with complex health needs, has added immense stress and chaos to our practice and clinicians.
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When I reached out to other clinic-based vaccination sites for operational advice, I discovered, to my great surprise, that there are almost none to be found in my part of the country. Of the 8,000 medical facilities in San Bernardino and Riverside counties, less than 2% are offering the Covid vaccine. Our small practice — with just 10 providers and 40 employees — comprises two of just 150 vaccination sites in the entire Inland Empire, an area that runs from Los Angeles to the borders of Nevada and Arizona, with a combined population of 4.5 million people, including 500,000 seniors.
Yet a campaign for mass vaccinating seniors cannot succeed without the help of local primary care providers. Given the novelty of Covid-19 vaccines, seniors need trusted advisers to provide personalized counsel on its benefits and risks. This counseling is already happening naturally — over the past months, we’ve seen hundreds of patients schedule appointments simply to discuss whether or not they should get the vaccine.
Integrating vaccine counseling with vaccine administration, as we have done, would greatly simplify the process for patients and providers, rather than having to redirect patients to unknown third-party vaccination sites with unknown appointment availability.
Vaccinating seniors in a clinical setting also helps providers improve quality of care by giving them an opportunity to provide physical care that has been postponed due to the pandemic. One-quarter of our clinics’ senior patients have been using telehealth exclusively since March 2020. Bringing them into the office for the vaccine enabled us to catch up on blood work and resolve other problems that can only be evaluated in person.
Sadly, the sheer intensity of running a Covid-19 vaccination site for seniors at this time makes it but a pipe dream for most primary care clinics, no matter how willing the providers and staff may be. Our practice is lucky to have a dedicated administrative team and call center, and enough financial cushion to reallocate time away from essential administrative functions towards vaccine operations. Yet even we have been so overwhelmed that we’ve had to seriously reconsider whether to continue the vaccination program. For smaller practices, offering Covid-19 vaccinations is utterly impossible.
But public health officials could implement a few simple initiatives to drastically reduce the administrative burden for providers and mobilize them in the vaccination effort. Here are three of them.
Change the timeline for vaccine utilization to account for the unique logistical challenges of vaccinating seniors. Currently, the California Department of Public Health mandates that we use all vaccines within five days of delivery but never gives us an expected delivery date. The inability to schedule patients ahead of time leaves us scrambling to book last-minute appointments every time a shipment arrives.
Seniors are especially time-consuming to contact: They tend to rely on phone calls as opposed to text messages or email. Of those we are able to reach, about half decline, citing fears of the vaccine’s novelty and side effects. Many of those who are interested have to call us back to schedule the appointment because they first need to find a way to get to the clinic. Making vaccine appointments for seniors for the next day is extraordinarily difficult, while making them a week in advance is highly feasible. If supply shortages continue to make it impossible to forecast delivery dates accurately, then the timeline for vaccination delivery should be extended by at least one week.
Accumulate a centralized waitlist of patients interested in getting vaccinated so providers avoid wasting time on contacting those who aren’t interested or who have already been vaccinated. An online waitlist would be most efficient, since many seniors have tech-savvy family members or caretakers who can help sign them up. The waitlist should gather demographic, contact, and insurance information. All vaccine administration sites should be able to access this shared list, as well as update it by removing the names of those they vaccinate.
A centralized waitlist can also serve as a digital hub that helps with pre-vaccination screening and post-vaccination care. We currently give patients a printed copy of the CDC’s “Pre-vaccination checklist for Covid-19 vaccines” when they come in for the vaccine, but the form takes a long time to fill out and creates traffic jams in the waiting room. A digital version that’s available on the waitlist website, in different languages, and completed during the sign-up process would be much more effective.
The waitlist website can also serve as a hub for post-vaccination care, with information on common side effects and suggested over-the-counter remedies. Setting up an after-hours vaccine hotline would be even more helpful, to provide support for the many patients who will experience unsettling fevers, chills, and aches, especially after the second dose.
Give funding for vaccine administration directly to providers instead of through health insurance claims. Our clinic is reimbursed only a fraction of the costs we’ve incurred, but even this partial reimbursement is painstakingly difficult to obtain for patients in managed care plans, who make up the majority of those we care for. We are told to bill administration costs for these patients directly to the Centers for Medicare and Medicaid Services (CMS) or to Medi-Cal (California’s Medicaid agency), rather than the managed care health plans, but doing so requires a different member ID that we cannot easily obtain. Even with the right ID, the process of setting up the claim to go to a different payer in our electronic medical record is so complex and error prone that it’s not worth the effort. CMS and Medicaid could save providers significant time and hassle by reimbursing them directly based on vaccination data, especially since this information is readily available through each state’s immunization registry.
The last month has been exhausting for all of us. Yet when I ask individual providers and staff members whether we should order more vaccines and continue vaccinating seniors, they are unanimously in favor of continuing the program.
“I just talked to one elderly couple yesterday who really need it,” a medical assistant told me. “I’m going to pray all weekend that we get our next shipment by Monday, so I can call them with good news!”
Lynn Wang is the managing director of TotalCare Walk-In Clinic, a medical group that provides primary and urgent care to more than 20,000 patients a year in the greater Los Angeles area.
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